Where do you live?

Address Information

Rental Information

Current Landlord Name

FirstLast

Current Rent Amount

Phone * Required

Alternative Phone

Email * Required

What is your source of income?

Income Source

Monthly Income

Tell us about your household and income

Please list all persons living in the household. Please complete monthly income amount for each. Please include income drawn from Social Security, SSI, KTAP, Unemployment, Black Lung, Child Support, Alimony, Grass Mowing, Babysitting, etc. For employment, you must include overtime, bonuses, etc.

Including yourself, how many people are living in your household? * Required

REVERIFICATION AUTHORIZATION TO OBTAIN CREDIT INFORMATION

Highlands Housing Corporation, their successors and/or assigns, as their interest may appear may re-verify the information or documents used in processing this loan. I hereby authorize release of information to the lender or its designee, by my employer, bank, accountant, mortgage lender, landlord, creditors, and other sources to verify the accuracy of documents and credit information the lender used in deciding whether to approve the loan.
I also grant permission to use a photographic copy of this form containing my signature to obtain any information regarding the items mentioned above.

Your Information

Name

FirstLast

Signature

Date - must be mm/dd/yyyy format

Spouse's Information

Spouse Name

FirstLast

Signature

Date - must be mm/dd/yyyy format

Privacy Act Notice: The information to be obtained will be used by the lender and any federal agency insuring, guaranteeing or purchasing the mortgage to determine whether you qualify as a prospective borrower under the lender’s and agency’s underwriting standards. The information will not be disclosed outside the lender and the federal agency without your consent except to the person or company verifying the information including, but not limited to, your employer, bank, lender, and any other credit reference as needed to verify other credit information and as permitted by law. You do not have to give us this information, but if you do not, your loan application may be delayed or rejected. The information we will obtain is authorized by Title 38, U.S.C., Chapter 37 (if VA); and 12 U.S.C., Section 1701 et seq. (if HUD/FHA)